An Issue of Vital Importance: Pressure Sore Prevention in the Intensive Care Unit

Northern Sydney Central Coast Area Health Service

This project was entered in the Baxter 2006 NSW Health Awards, Education and Training category.

 Presentation given at the 2006 NSW Health Expo.

Contact: Rosalind Elliott

Abstract

The healthcare literature reports much higher pressure sore prevalence rates in the intensive care unit (ICU) than the general hospital population (Keller et al 2002). In order to reduce the number of pressure sores in ICU a quality improvement project was initiated. Additional objectives included increasing the reliability of prevalence data and providing objective data to clinicians about the origin of pressure sores. The program included monthly prevalence audits which included information giving about risk factors and preventative strategies. Laminated information cards were placed in each clinical area. More formal presentations about all aspects of pressure sore prevention were also provided. Prevalence data were disseminated via the ICU newsletter and included information about pressure sore prevention. As a result the prevalence of pressure sores in ICU has decreased significantly. Most of the nurses in ICU have received academic detailing about pressure sore prevention. Specific areas of concern are being proactively addressed eg heel sores.

Aim

The project had three broad aims for pressure area care; to reduce the prevalence of pressure sores, identify areas of improvement and to improve the uptake of prevention strategies

Background

It is well known that critically ill patients are at higher risk of developing pressure sores than general hospital patients (Keller et al 2002). Prevalence or ‘snapshot’ rates of pressure sores range from 13.6% to 82% in intensive care unit (ICU) patients which contrasts with 3% to 20% for hospital ward patients. A prevalence survey at the Royal North Shore Hospital including ICU revealed a higher than acceptable pressure sore rate. Simultaneously anecdotal reports during telephone follow-up conversations with former patients revealed problems with heel pressure sores. A hospital wide task force was created to address the problem. The problem was given high priority by the ICU nursing education and management team and a program was created to address it.

Method

A prevalence survey was conducted by clinical skin assessment and pressure sore prevention experts in four separate clinical areas of the Royal North Shore Hospital including the intensive care unit and the care of the elderly ward. The baseline data from this survey and subsequent monthly ICU prevalence surveys were used to gauge improvements in pressure sore rates after the implementation of a hospital wide pressure sore prevention strategy. These surveys indicated a higher than acceptable rate of pressure sores in the ICU (50% of patients in ICU had pressure sores) and that many high risk and very high risk ICU patients were not placed on a pressure relieving mattress prior to the audit (only 25% of high to very high risk patients) .

Our bedside colleagues were engaged in the project by providing academic detailing which included the use of the Waterlow pressure sore risk assessment Scale (WPS), preventative strategies, notification procedures and skin assessment. Monthly feedback was presented to bedside nurses in the ICU newsletter and included raw prevalence data, areas of particular concern e.g. heels, and information on how to obtain pressure relieving devices and grading sores and encouragement as pressure sore rates plummeted. Regular presentations incorporating these topics were provided by clinical nursing experts in the in-service program. Care was taken to select clinicians who were highly regarded by their colleagues that is opinion leaders. In addition every six months a wound and skin care workshop was offered to the nurses to increase knowledge about pressure sore prevention and wound healing in general. Pressure sore prevention constituted a significant portion of this workshop. At first interest in the workshop was low (prior to the project at least workshop was cancelled) however one year into the project interest increased to the extent that the workshops have waiting lists and plans have been made to provide them more frequently.

During the monthly surveys in ICU the following data were collected for each patient:

• Number, stage and location of pressure sores
• The type of pressure prevention strategy employed

The data were entered into an Excel spreadsheet and the frequency of sores counted. Since prevalence data violates the assumptions of interpretative statistical methods statistical analysis was not performed, data were reported in raw numbers and percentage rates.

Planning and Implementation

The monthly prevalence surveys conducted in ICU and delivery of information to bedside clinicians formed the basis of this project. After the results of the baseline survey were revealed audits were planned in ICU every month. A continuous quality improvement process underpinned the project. The results of each survey were reviewed each month and any areas of concern were emphasised in the academic detailing and presentations provided in subsequent months. For example focused preventative interventions such a ‘pillow campaign’ (encouraging colleagues to place a pillow under the lower part of each leg to keep the heel clear of the bed) were employed when the number of heel sores was unusually high. The project has lead to the initiation of a separate quality program developed with orthotic technicians to improve cervical-collar care and use of pressure relieving pad to reduce the rate of occiput sores. The results of the survey and information about particular areas for improvement and focused interventions were presented in the ICU monthly newsletter.

Outcomes and Evaluation

All of the patients surveyed were at risk of developing pressure sores; percentage per WPS was; at risk (> 10 *) 20%, high risk (>15 *) 30% and very high risk (>20 *): 50%.The overall rate of pressure sores reduced from 50% to 8.3% (see below).

There was a downward trend in all stages of sores that is between 5 to 6 stage I and II sores (2003/4) to between 2 to 3 (2005) per survey. The origin of the sore remained constant, 75% acquired in ICU and 25% elsewhere. As did the site of pressure sore development; 60% on heels, 30% on the sacrum and 10% other, including occiput. The use of pressure relieving devices for high and very high risk patients increased from 75% during 2003/4 surveys to 95-100% during 2005/6.

Academic detailing has been provided to 90% of all bedside ICU nurses. There has been an anecdotal increase in knowledge and fewer attitudes of futility about pressure sore prevention. There are oversubscriptions to ICU nursing wound/skin care workshops.

Future Scope

The intense individual and group approach to the dissemination of clinical practice guidelines and feedback results to clinicians in a timely manner has reduced the number of pressures sores in ICU patients at RNSH. This method of practice improvement and development has been adopted for other aspects of care for example improving ventilator safety and reducing medication errors within the ICU at the Royal North Shore Hospital. We recommend the use of this powerful training approach in other organisations and contexts to improve clinical practice. The strategy may also be a useful way to promote the use of research in clinical practice. 

References

Keller, B., Wille, J., van Ramshorst, B. and Van der Werken, C. (2002) Pressure ulcers in intensive care patients: a review of risks and prevention, Intensive Care Medicine, 28: 1379-1388